When Should I Start Baby Food?

When to start baby food? The timing on starting baby food may seem confusing. If you survey your neighbors, your own moms, the doctors you see, and the child care or daycare providers who help you, I bet you’d get about 4 different answers backed with 4 different theories and rationales. The reason is, the pendulum on when and how to start baby food has changed. Bits and pieces of old data mixed with contrasting new research findings are getting tossed around. Most new parents I talk with are a bit puzzled on what is truly best.

It’s okay to start your baby on baby foods or “complementary foods” when they show signs of readiness if they are at least 4 months of age. Signs of readiness include watching you eat (following your spoon’s every movement at a meal), lip smacking and licking when they smell food, and opening their mouths when you present them with a spoonful of food. Most babies ready to eat have also doubled their birth weight and started cooing and laughing, sitting up with assistance, and rolling over.

I used to advise families to wait until 6 months to start baby foods but new research over the last couple of years has caused me to change my tune.

Starting baby food at 4 months of age can potentially increase iron stores in breastfed babies and may help all babies prevent allergic disease. Although the World Health Organization (WHO) recommends exclusive breast-feeding for babies until 6 months of age, there may be some benefit and risk reduction with an earlier start on baby food. The WHO guidelines make the most sense in low-income countries where food and water can be contaminated and unsafe. Here in the US and in other high-income countries, adding complementary baby foods earlier may be advantageous.

Over the last 5-10 years there’s been a big pendulum shift. It used to be that pediatricians recommended holding on some foods until children were 1 year, 2 years, or every 3 years of age to protect against food allergies. New data over the past few years is shaping rationale and age recommendations to 4 months of age. Some believe by advising families to avoid high-allergic foods like peanut, egg, or fish we may have contributed to increases in food allergies.

If there are no food allergies in your family, you can start baby foods slowly at 4 months of age. If food allergies are prevalent in your family, I continue to suggest getting the advice of an allergist on board. As I understand it, most data show even in children with increased risk, earlier introduction tends to be more protective against development of allergies. The only “forbidden” food for babies before 1 year of age is honey (there’s a theoretic risk of botulism).

There’s no clear scientific or medical evidence that the order in which you start food changes your baby’s health although new research (below) can help guide you. At four months, your baby eats a liquid diet. By 1 year of age, you want them on a mostly solid diet. How you get there may not matter much. The goal is to offer foods that your family loves and to instill a love for eating…

Feeding Babies At 4 Months Of Age

(FYI: content in these bullets was edited on March 6th at 10am to reflect great insight & help from commenters…)

Watch for signs of readiness in your 4-6 month-old. Offer thin, liquid-like pureed baby cereal, fruit, or veggies by spoon once daily in the beginning. Never push a spoon through a baby’s pursed or closed lips. If they turn their head away from you, respect them and try again tomorrow. There is NO RUSH is starting solids and may be protective benefits of waiting even until 6 months. If your baby is exclusively breast-fed, you can consider waiting until 6 months of age to offer complementary foods. Talk with your doc about possible additional iron supplementation at or around 4 months of age that they may suggest. Here’s the up to date AAP statement on breastfeeding recommendations. In the policy, they state, “Complementary food rich in iron and zinc should be introduced at about 6 months of age. Supplementation of oral iron drops before 6 months may be needed to support iron stores.” A nice summary in The Wall Street Journal highlights some good insight about the lack of a rush.

There is no single, perfect first food. We often used to recommend rice cereal as a near perfect first food because you could mix flakes with breast milk or formula to a really nice, liquid-like consistency. However, with new information out this past year about arsenic levels in rice cereal, it’s now recommended we only feed babies rice once weekly. So start with a cereal, a fruit, or a veggie as a first food. Introduce the same food daily for a day or two. Give your baby a chance to explore the new texture and flavor. Then 3 days later, add on another new food. That way in the rare case of an allergy or intolerance, you’ll know what food to blame.

A study published in Dec 2012 randomized children at 4 months to get complementary foods in addition to breast milk. Growth was great. Of the 100 mother-infant pairs, the growth was no different but iron levels were better in those with food started. Fortunately, iron levels were adequate in exclusively breast-fed infants, too. Most common foods added after 4 months of age were cereal, formula and fruits puree.

Starting complementary foods at 4months of age may help reduce allergies and asthma. A recent 2013 study in The Journal of Allergy and Clinical Immunology found that adding wheat, rye, oats and barley before 5.5 months, fish before 9 months, and egg before 11 months was associated with lower rates of asthma, allergic rhinitis, and allergic response in the blood (IgE sensitization). The study also found that babies who received breast milk for 9 ½ months or more also had lower rates of asthma. It may be more important how long you breastfeed versus just breastfeeding and assorted food choices when it comes to allergy protection.

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42 Comments to “When Should I Start Baby Food?”

Great article! Our pediatrician says no sushi or other raw fish till kiddo is three. What do you think of that recommendation in light of the only “forbidden” food being honey before age 1? Would love to hear your thoughts and have saved this article for baby #2 arriving shortly!

Hi Erika,
Huh. I have no idea if there is data to back up no sushi until age 3. Theoretically, I would presume his/her recommendation comes out of concern for infection from raw & undercooked food. Unsure why it’s “safer” for a 3 year-old than a 2 year-old. Will do some reading to see if I can find anything…

It makes me wonder why they say no fish before three when in other countries like Japan do they stop feeding their children fish and sushi before three? I think that everything in moderation is what is key. If you feed your child sushi everyday, yes that is harmful due to mercury toxicity but it is in adults as well. I wouldn’t feed my child old sushi from 7 eleven but I wouldn’t eat that crap either. Its just about being realistic and rational about giving our child good nutritious food! Loved the article about starting your child earlier I think also not avoiding food that are more common “allergy foods”. Definitely think kids that eat the veggies and sushi and different foods earlier on are less picky and less likely to get allergies!

Fantastic review, and as usual, very well written for parents. I’m definitely forwarding this to my patients and fans on my blog and Weibo. I’m a family doctor and I’ve also been interested in this changing debate about earlier feedings. The latest evidence indeed does suggest earlier feeds, and I’ve also already changed my practice with this new data.

Why start complementary foods when the study you cite clearly shows that there was NO anemia in BF infants? As you state “Fortunately, iron levels were adequate in exclusively breast-fed infants, too” why go against clear evidence-based recommendations for exclusive BF for 6 months?
I refer you to http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552.full.pdf which clearly shows the benefits of exclusive BF for 6 months >>> exclusive BF for 4 months.

As you know there is significant controversy here. I agree–the data in the aforementioned study is great — ferritin levels were higher in complementary food + breast milk group (70) versus exclusively breast fed babies (44 µg/L). But both were GREAT.

The Amer Acad Allergy, Asthma & Immunology summarizes the differing advice well (from link in post):
“Between 4 and 6 months of age, complementary foods are
necessary to support growth and to supplement nutritional
needs. The introduction of complementary foods should be
delayed, however, until the infant is able to sit with support
and has sufﬁcient head and neck control.
The AAP recommends the introduction of complementary
foods be delayed until the infant is at least 4 months old, but
exclusive breast-feeding is preferred until 6 months of age.
The expert panel from the European Academy of Allergology
and Clinical Immunology recommends introduction of
complementary foods between 4 and 6 months of age in
breast-fed or formula-fed infants.1,5 The World Health
Organization recommends exclusive breast-feeding for the
ﬁrst 6 months of life.”

As I understand it:
the breast feeding council for the AAP recommends exclusive breastfeeding until 6 months
the nutrition council for the AAP recommend starting complementary foods with iron at 4+ months.

Each angle and recommendation has its benefits and rationale. But the allergy data statements seem to stay safe by saying starting introduction between 4 and 6 months.

If a family doesn’t want to add complementary food until 6 months, the alternative advice can be to start supplemental iron.

Here’s info from nutrition council — in regards to preventing Iron Def Anemia (and impairing development):
“Supplementation also resulted in better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months. Thus, it is recommended that exclusively breastfed term infants receive an iron supplementation of 1 mg/kg per day, starting at 4 months of age and continued until appropriate iron-containing complementary foods have been introduced (Tables 3 and 4).”
REFERENCE: http://pediatrics.aappublications.org/content/126/5/1040.full

Unfortunately the designations behind your names says it all. I’m so happy to see an MD with an IBCLC. Why doesn’t every pediatrician have an IBCLC in their office? And have continuing education in breastfeeding? It’s the single most important thing for their most vulnerable patients- why don’t more understand it? I can’t tell you how many of my friends and family were given incorrect information by their pediatricians that negatively affected their breastfeeding relationships. Just terrible!

In February, 2012, BMJ Open published this article on baby-led weaning (BLW) and avoidance of pureed foods: http://bmjopen.bmj.com/content/2/1/e000298.full I was very impressed with their conculsion that, “infants weaned through the baby-led approach learn to regulate their food intake in a manner, which leads to a lower BMI and a preference for healthy foods like carbohydrates. This has implications for combating the well-documented rise of obesity in contemporary societies.”

I read this article just as I was starting my 4th child on foods. My third child never wanted to quit pureed foods, and he’s now my only child that consistently refuses veggies. With my 4th, I went with the BLW and loved it.

I just don’t see how this makes any sense. Given the importance of gut health in a developing infant, why would anyone want to rock the boat unnecessarily? For what purpose? Solid food at 4 months is only for fun and takes the space nutrient dense formula or breast milk could and should occupy. How about the ridiculous rise in all problems immune and emotional in children? You don’t think there’s any possible tie to what we’re doing to their developing gut?
This is so disturbing. I’m appalled. As a parent with one child who’s gut was compromised at birth with IV antibiotics, which we’re still trying to correct 3 years later while navigating gluten and dairy intolerances and a penicillin allergy, early introduction of solids is a bad plan. Extremely bad. Please reconsider your stance and do further research.

Hi Stacy,
I think it’s unfair to discredit all pediatricians who aren’t lactation consultants. We have lactation support in our office and I work so hard to support families in continuing breastfeeding. After my own challenges with nursing and seeing nearly 10 consultants in the first few week/months of my first born’s life, I did learn quite a bit about the challenges of nursing.

That being said, we don’t get a lot of education on breast feeding in training…

In my experience, many families with whom I report this research will start foods at 4 months. Many families will continue exclusive breast feeding (with or without Iron and Vita D) until 6 months. I feel it’s my job to discuss the recommendations, the rationale and let moms and dads decide what they would like to do introducing new foods and following their babies cues.

I’m certainly not saying you MUST start foods at 4 months of age but I’m also not saying you must wait, either.

Actually the golden era and their children the baby boomers were less likely to breastfeed and they had less emotional and physical ailments as children. Correlation does not equal causation. I am doing what my mother and grandmothers did, you pay attention to your child and use your instincts. If breastfeeding is natural then my instincts work just fine in telling me how to take care of my child. Breastfeeding did not work for me due to medical reasons, but I also stopped because she screamed and cried and ate every 45 min for 45 min for 2 weeks and I had not slept in that time. She was 8.5 lbs at birth and already holding her head up and smiling at the hospital. Every child is different and individual in developemental needs.

From my experience breast feeding…perhaps they encourage exclusive breastfeeding til 6 months, because any introduction to other foods or liquids would decrease milk supply. By 6 months your milk supply is pretty well strong enough to withstand introduction to complementary solids. I know the difference between 4 and 6 months is small, but in the time line of a breastfeeding mom and child, it does not feel small.

Our nursing relationship suffered when I started solids at 4 months. My daughter went through a horrible nursing strike and would nurse less than 4 times a day. This happened for 2 weeks. What followed after that was a drastic decrease in my milk supply, which only furthered our struggle. With patience and perseverance, and a lot of help from peer support and an LC, we got my milk back up and resumed nursing. My daughter will be 1 this month and we are still going strong, with no signs of stopping.

In the beginning of most nursing relationships, milk supply is heavier. As time goes on, the body regulates the milk supply to the demand of baby, often times decreasing. Lots of moms lose the engorged feeling and or stop leaking. At four months, perhaps the milk is not completely regulated yet, and introduction to solids could disrupt the supply and demand.

I waited to feed solids until my children were really ready. Pincer grasp, sitting themselves up from laying down, lack of tongue thrust. My oldest was about 9 months and my younger 2 were closer to 11 months before they took a bite. My older 2 have ZERO food allergies while my youngest (16 months) had many food allergies before 3 months of age and was reacting to the triggers through my breastmilk. Since eliminating those foods from my diet, he is no longer reacting. He has never had a bite of any of the things he was allergic to. I realize this anecdote is not enough to change this recommendation and that there are always exceptions, however, exclusive nursing until the child is really ready and has met certain physical milestones is more important that the number on the calendar. Also, I think there should be more than 2-3 days between foods… more like 5-7 as there are several types of allergies that have a slower reaction and if only spacing by 2-3 days, the parent may see the reaction and think it matches with a newer food and put the child at greater risk.

Every mom and baby are different! Some find it ok to start at 4 months, some at 6 and some at 8. A lot of people tend to over think this subject, maybe just to have a debate like all other parenting topics. I started my kids around 4 months, when they stare at me and smack their lips while I’m eating. What did they do in the old days? Babies this age got cow’s milk…gasp! I continue to breast/forumla feed until a year. Introducing solids had no effect on breastfeeding for them. My kids ages 6 1/2, 4 1/2, 2, and 5 months are all completely healthy so I know I made the right decision for us. :o)

“As I understand it:the breast feeding council for the AAP recommends exclusive breastfeeding until 6 months the nutrition council for the AAP recommend starting complementary foods with iron at 4+ months.”

As of January 2012, The Committee on Nutrition (CON)and the Section on Breastfeeding of the AAP both say 6 months before starting complementary foods and the CON hasn’t recommended rice cereal (the title of the presentation at the AAP national meeting was “Throw Away the Rice Cereal” for a few years now. Exclusive breastfeeding for 6 months is now recommended by the AAP,WHO, CDC, ACOG, Surgeon General, DHHS. Simply focusing on the issue of food allergies ignores the impact on the immune system, obesity prevention and a host of other factors.

Thanks, Dr Thomas, Thanks for chiming in. Can you help me find the CON statement encouraging a strict wait until 6 months for complementary food? Here is the full paragraph from Dr Greer’s and the committee on nutrition’s input, here is the full paragraph from the Nov 2012 report that I think nicely demonstrates where there is a slight difference of opinion.

Term, Breastfed Infants
Infants who are born at term usually have sufficient iron stores until 4 to 6 months of age. Infants born at term have high Hb concentration and high blood volume in proportion to body weight. They experience a physiologic decline in both blood volume and Hb concentration during the first several months of life. These facts have led to the supposition that breastfed infants need very little iron. It is assumed that the small amount of iron in human milk is sufficient for the exclusively breastfed infant. The World Health Organization recommends exclusive breastfeeding for 6 months, and the American Academy of Pediatrics (AAP) has recommended exclusive breastfeeding for a minimum of 4 months but preferably for 6 months. Exclusive breastfeeding for more than 6 months has been associated with increased risk of IDA at 9 months of age. Recommendations for exclusive breastfeeding for 6 months do not take into account infants who are born with lower-than-usual iron stores (low birth weight infants, infants of diabetic mothers), a condition that also has been linked to lower SF concentrations at 9 months of age. In a double-blind study, Friel et al demonstrated that exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher Hb concentration and higher mean corpuscular volume at 6 months of age than did their unsupplemented peers. Supplementation also resulted in better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months. Thus, it is recommended that exclusively breastfed term infants receive an iron supplementation of 1 mg/kg per day, starting at 4 months of age and continued until appropriate iron-containing complementary foods have been introduced (Tables 3 and 4). For partially breastfed infants, the proportion of human milk versus formula is uncertain; therefore, beginning at 4 months of age, infants who receive more than one-half of their daily feedings as human milk and who are not receiving iron-containing complementary foods should also receive 1 mg/kg per day of supplemental iron.”>Nov 2012 report.

The recommendation for obesity protection is to avoid early introduction before 4 months of age. This Pediatrics study found an increase risk of obesity (at age 3) in formula-fed or partially breastfed babies who started solids before 4 months. Can you direct me to a study that evaluates the effect when breastfed (or partially breastfed) babies start complementary foods between 4 and 6 months? Not trying to cherry-pick studies, so if you have more info or summary work, would love to see it and share it here. Thanks.

Dr. Greer is no longer Chair of the CON and hasn’t been for a few years. The AAP leadership asked the CON and Section on Breastfeeding to come to a consensus on complementary foods before the new policy on “Breastfeeding and the Use of Human Milk” could be published. That consensus was achieved. The policy is here: http://pediatrics.aappublications.org/content/129/3/e827.full

Your blog was about food allergies and timing of foods. I’m simply pointing out that there is so much more to consider than that single issue. We need to consider the needs of the whole patient, not just their food allergy risks. The recommendation of 6 months, with so many agencies trying to help families reach the goal, is hard to ignore. Especially in Washington State where you are, where breastfeeding initiation rates are around 90%- your patients want that evidence-based support.

Thanks, Dr Thomas.
The comment I wrote in reply to you early this AM with all the embedded text from the policy isn’t working….hold on a minute….will get that back up. But in the meantime,

Thanks so much for the info and clarification. I completely agree about whole patient and am appreciative of you helping improve how I say this and present this data.

Because this blog is getting read so much right now, I’m planning on adding another bullet to the text to help characterize both the data you point out but improve the tone. The confusion I feel in competing recs (over the past few years) I suspect is felt by many pediatricians. One thing I really like was a quote from the WSJ article yesterday and helps elevate the moderate slow start families can have in prevention of allergies,
“Dr. Wood said he tells parent they don’t need to feel pressured to do an early introduction. “You can do whatever you want because we’re not sure what makes a difference,” he said. This was Dr Robert Wood, from Johns Hopkins.
WSJ article: http://online.wsj.com/article/SB10001424127887324662404578334423524696016.html

More evidence that protecting against development of food allergies is multi-factorial — it’s a complex mix of family history and inherited risk, feeding, food introduction (data above), and potentially exposures in early life (to things like antibiotics, etc).

There are clearly several things to consider when determining best time to introduce solids. One is obviously how to factor in the introduction of iron-rich foods to prevent iron deficiency and/or iron deficiency anemia. Has anybody considered the common birthing practice of cutting the umbilical cord immediately after birth, rather than allowing a few minutes for blood in placenta to fully transfuse into the newborn infant before clamping? My understanding is that studies have shown babies for whom the cord clamping was delayed had better iron stores in later infancy than those for whom cord was immediately clamped. Iron deficiency in older infants and toddlers is so common- I wonder if we are creating and/or contributing to this problem with immediate cord clamping. Thoughts on this?

You’re referring to delayed cord clamping. The idea of transfusing more maternal blood into baby’s circulation immediately following birth. The goal of starting with more blood cells around (hence more iron) to avoid dips in iron and subsequent anemia that can occur during infancy until babies ramp up eating iron-rich foods in addition to breastmilk.

Here’s a Dec 2012 statement from The Amer College of Obstetricians & Gynecologist reviewing the data (this was affirmed by The Amer Academy of Pediatrics. Their conclusion differs for full-term versus preterm babies.

“Currently, insufficient evidence exists to support or to refute the benefits from delayed umbilical cord clamping for term infants that are born in settings with rich resources. Although a delay in umbilical cord clamping for up to 60 seconds may increase total body iron stores and blood volume, which may be particularly beneficial in populations in which iron deficiency is prevalent, these potential benefits must be weighed against the increased risk for neonatal phototherapy. In addition, no difference is apparent between infants who undergo early umbilical cord clamping versus those who undergo delayed umbilical cord clamping with respect to immediate birth outcomes, such as Apgar scores, umbilical cord pH, or respiratory distress caused by polycythemia (51). Although maternal outcomes have not been rigorously studied, the incidence of postpartum hemorrhage is reported to be similar between immediate umbilical cord clamping groups and late umbilical cord clamping groups.”

Dr. Swanson – While you were doing literature searches for this post, did you find anything about recommendations regarding women with autoimmune conditions breastfeeding? I myself have had asthma and environmental allergies since childhood. As a young adult I developed Hashimoto’s Disease and food allergies. My husband and I are trying to start a family, and I can’t help but wonder if in my case (and the case of other women with autoimmune disease) breast might not be best.

Dr. Sriraman- Why would some children be biologically
programmed to crave solid foods at 4 month as evidenced by them
making chewing motions with their mouths, intense focus on anyone
eating solid foods, reaching and grabbing for solid foods, etc.
Should we ignore nature and refuse to give them what some infants
naturally desire at this age? One child may have the instinct to
eat solid food at 4 months; another at 6 months. Listening to a
child’s natural instincts won’t harm them; it is what is best for
them.

I think I got the following info from a no longer available website, ProMom.org.
The iron in breastmilk is adequate for an infant under a year of age. Iron fortified foods, including formula and baby cereal, have a form of iron which needs to be in high enough concentration to force its way through the intestinal wall, sometimes leading to perforation.

My own experience was that my kids did not receive anything aside from breastmilk and water until they had developed a pincer grasp. I finished breastfeeding around age 2. Didn’t plan it, it just seemed right.

The most formal recs are outlined both in the WSJ piece and in my post. They are from AAAI (link in the post) and recommend early, not late, introduction of foods like peanut. If you’re trying to decrease allergy risk, start by slowing introducing foods one at a time and then gradually pepper in “high allergy” foods like peanut, egg, fish, and shellfish.

They do note this:
“Complementary foods can be introduced between 4 and 6
months of age.
There are no current data available data to suggest that cow’s
milk protein (except for whole cow’s milk), egg, soy, wheat,
peanut, tree nuts, ﬁsh and shellﬁsh introduction into the diet
need to be delayed beyond 4-6 months of age. Therefore,
complementary foods may include the highly allergenic foods
once a few other complementary foods are tolerated ﬁrst.
New data are emerging that suggest the early introduction of
the highly allergenic foods may reduce the risk of food allergy.
Highly allergenic foods are best ﬁrst introduced at home,
rather than at a day care or at a restaurant”
Here’s the link from AAAI:http://download.journals.elsevierhealth.com/pdfs/journals/2213-2198/PIIS2213219812000141.pdf

Dear Doctor,
My nephew used to weigh at 28th percentile when he was less than 2
years old. Then his pediatrician asked his parents to feed him more.
At a point, he was 91th percentile in weight…then I always advised
his parents to feed him better(both parents are dentists from UW and
UTexas). Now, he just turns 7 years old last week. His weigh has been
fluctuated between 84th-86th percentile weight.

I’ve read on diets since 1992…and I am also a health professional.
Everything about diet would be in my “blood” by now. We are blessed
that there have been health professionals, doctors, dentists and
pharmacists among our family by 3rd generation and one of our
medical doctor great uncles actually established the Vietnamese Army
Medicine and was also mentioned in a book of Ted Morgan’s. I’ve
always liked to know more knowledge from people who are slim, “by
chance” so that I could teach my nephews and niece… I.e. what
staples,food, desert, drink in a typical day, week…; how many meals,
snacks per day?

I’m aware that this blog post is daily old (yet I’m still hoping to get a response from you 🙂 ). My son was 10 lbs when he was born and I was/am definitely not over weight (natural weight is 103 lbs) or an unhealthy eater while pregnant. He is currently 3 months old and is 16.5 pounds and 27 inches long. I personally feel like he’s ready to start purees that way he will be ready for finger foods sooner. He’s a very hefty eater and until pediatricians learn my family history, they just think he’s on the track to obesity. He’s definitely just a big baby and will mostly be a tall man. He’s off the charts in size and has started teething. I’ve heard multiple theories from different pediatricians about when to start him on purées and solids and I wanted to get your opinion.

He’s not breast fed, only getting breast milk for the first two weeks of his life.http://commonhealth.wbur.org/2014/02/sibling-study-finds-no-long-term-breastfeeding-benefits-for-kids
This study really solidified the decision to make him a formula baby for me. I’m definitely in the statistics for him to be a traditional breast fed baby (I have a great bond with my child and we practice EC, for any mothers finding it necessary to haggle me about my parenting and “lack of nurturing”); however, honestly the trade off wasn’t there for me and knowing that multiple studies have proven that there aren’t any long term benefits for a breast fed baby I just didn’t care to continue the misery (lack of sleep, discomfort due to breast surgeries).

What’s your opinion on eggs – I think it’s the yoke specifically – for kids as young as 5 or 6 months. (Assuming there are no allergies in the family.) I read this somewhere on one of the natural food type blogs and it seems counter to other things I’ve read.

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